Screening c cervix slideshare 2015 (1)
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Screening for premalignant cervical lesions in Egypt is important given the high incidence of cervical cancer. Visual inspection with acetic acid (VIA) is recommended for screening in developing countries due to its low cost, simplicity, and ability to provide immediate results and treatment. Mansoura University experience found VIA to be a sensitive screening method, detecting cervical lesions. While a positive VIA does not always indicate cancer, it allows for low-cost screening and identification of suspicious lesions requiring further evaluation or treatment.
Screening c cervix slideshare 2015 (1)
- 1. Screening for Premalignant cervicalScreening for Premalignant cervical Lesions In EgyptLesions In Egypt BYBY Prof.Prof. Mohammad EmamMohammad Emam Director Of Early Cancer Detection UnitDirector Of Early Cancer Detection Unit OB & GYN Dept.OB & GYN Dept. Mansoura Faculty of Medicine-Egypt.Mansoura Faculty of Medicine-Egypt. 20152015
- 2. Screening GenerallyScreening Generally • Is to seek aboutIs to seek about certain problemcertain problem in certain highin certain high risk gp.risk gp.
- 3. Who is at riskWho is at risk?? Women who have had more than one partnerWomen who have had more than one partner Women whoWomen who’’s partner (s) has had more thans partner (s) has had more than one sexual partner.one sexual partner. Women with other STDsWomen with other STDs
- 4. Who is at riskWho is at risk?? Women with immune problems:Women with immune problems: – Steroid medicationsSteroid medications – Transplanted organsTransplanted organs – ChemotherapyChemotherapy – HIVHIV Women who smokeWomen who smoke 11stst intercourse before Age 18intercourse before Age 18
- 5. Ideal Screening MethodIdeal Screening Method Adequate sensitivity and specificity.Adequate sensitivity and specificity. yield reproducible results.yield reproducible results. Cheap, simple and easy to apply.Cheap, simple and easy to apply. Without side effects or complications.Without side effects or complications. Painless .Painless . Socioculturally acceptable.Socioculturally acceptable. Infrastructures are easily available.Infrastructures are easily available.
- 6. RationaleRationale 1.1. Prevention is better than cure.Prevention is better than cure. 2.2. Most Cancers Develop In The UnscreenedMost Cancers Develop In The Unscreened And The Under screened populationsAnd The Under screened populations
- 7. Cervical CancerCervical Cancer WorldwideWorldwide 230,000230,000 womenwomen diedie of cervical cancerof cervical cancer every yearevery year – 80 % occur in80 % occur in developingdeveloping countries.countries. ““WHO , Cervical Cancer Screening in DevelopingWHO , Cervical Cancer Screening in Developing Countries. Report of a WHO Consultation. 2001”Countries. Report of a WHO Consultation. 2001”
- 8. Incidence of Cancers inIncidence of Cancers in Egyptian WomenEgyptian Women 00 55 1010 1515 2020 2525 BreastBreast CancerCancer CervicalCervical CancerCancer OvarianOvarian CancerCancer UterineUterine CancerCancer PercentPercent Source: GLOBOCAN 2000.Source: GLOBOCAN 2000.
- 9. RationaleRationale In developed countriesIn developed countries:: – Cervical cytology is considered to be the only test known toCervical cytology is considered to be the only test known to reduce cervical cancer .reduce cervical cancer . In developing countries ( Low resources ):In developing countries ( Low resources ): – An organized screening program is difficult toAn organized screening program is difficult to implement ( some counteris like Pakistan , Indonesiaimplement ( some counteris like Pakistan , Indonesia have started)have started)
- 10. RationaleRationale In Egypt:In Egypt: No national screening program for cancerNo national screening program for cancer cervix although in developed countries thecervix although in developed countries the screening is in adulthood ,screening is in adulthood , Only sporadic reports regarding the prevalenceOnly sporadic reports regarding the prevalence in some governorates ( Dakahlia, sharkia ,in some governorates ( Dakahlia, sharkia , Assuit, and minia ), utilizing VIA .Assuit, and minia ), utilizing VIA .
- 11. WHO guidelines for screening and tttWHO guidelines for screening and ttt ::developing countries :developing countries :((of CIN ( 2013of CIN ( 2013 – where screening with an HPV test iswhere screening with an HPV test is not feasible: screen with VIA and treat.not feasible: screen with VIA and treat. – Screen-and-treat strategies involve ttt withScreen-and-treat strategies involve ttt with cryotherapy, or LEEP when the patient iscryotherapy, or LEEP when the patient is not eligible for cryotherapy.not eligible for cryotherapy.
- 12. SeriousSerious WidespreadWidespread Diagnosable in early stages.Diagnosable in early stages. TreatableTreatable Cancer cx. Screening programs are inCancer cx. Screening programs are in adulthood.adulthood. ButBut ov. cancer programs are still in relativeov. cancer programs are still in relative infancy,infancy, why?why? Cancer Cervix Is an IdealCancer Cervix Is an Ideal Disease For ScreeningDisease For Screening
- 13. Screening Of Cervical CancerScreening Of Cervical Cancer is in adulthood.. Whyis in adulthood.. Why?? 1.1. Screening detects Premalignancy.Screening detects Premalignancy. 2.2. PremalignancyPremalignancy can be detected bycan be detected by noninvasive means.noninvasive means. 3.3. Good prognosis of early stage.Good prognosis of early stage. 4.4. Premalignant Course is slowPremalignant Course is slow..
- 14. Screening Of Cervical Cancer is inScreening Of Cervical Cancer is in adulthood.. Why ?adulthood.. Why ? ContCont…… 5.5. Effective treatment modalities forEffective treatment modalities for premalignant lesions .premalignant lesions . 6. C6. Cervical cancer incidence is reduced byervical cancer incidence is reduced by about 90% inabout 90% in developed countriesdeveloped countries withwith -organized screening programs.-organized screening programs.
- 15. Gold standard ScreeningGold standard Screening test For Cancer Cervixtest For Cancer Cervix ☼ PAP smear test is considered to be the gold standard . ☼ Has limitations ?
- 16. •CollectionCollection •ReadingReading •ReportingReporting Limitations Associated withLimitations Associated with Pap SmearPap Smear
- 17. Pap Smear PreparationPap Smear Preparation
- 18. Ayres’ spatula & endocervicalAyres’ spatula & endocervical brushbrush
- 19. Broom type samplerBroom type sampler
- 20. Differences between the Bethesda & PapanicolaouDifferences between the Bethesda & Papanicolaou SystemSystem Includes the diagnosis of HPV infections andIncludes the diagnosis of HPV infections and limits use of the termlimits use of the term “atypia”.“atypia”. squamous intraepithelial lesion =squamous intraepithelial lesion = SIL:SIL: – low-grade SIL = HPV change and CIN Ilow-grade SIL = HPV change and CIN I – high-grade SIL = CIN II and CIN III lesionshigh-grade SIL = CIN II and CIN III lesions
- 21. PAP Smear NormalPAP Smear Normal::
- 22. LSILLSIL Dysplastic nuclear changes, binucleationDysplastic nuclear changes, binucleation
- 23. HSILHSIL Enlarged nucleus, less cytoplasm (increased N:C ratio).Enlarged nucleus, less cytoplasm (increased N:C ratio). Irregular nuclear membraneIrregular nuclear membrane
- 24. objectiveobjective To highlight :To highlight : –Alternative methods forAlternative methods for screening of premalignantscreening of premalignant cervical lesions suitable in Egyptcervical lesions suitable in Egypt –Mansoura Experience.Mansoura Experience.
- 25. What areWhat are Alternatives toAlternatives to Pap SmearPap Smear??
- 26. Alternatives to Pap smearAlternatives to Pap smear – Automated pap screening.Automated pap screening. – Visual inspection with acetic acidVisual inspection with acetic acid (VIA), with magnification (VIAM)(VIA), with magnification (VIAM) &&iodineiodine (VILI).(VILI). – HPV testing.HPV testing. – Polar probe.Polar probe. – cervicographycervicography
- 27. HPV testingHPV testing Detect High Risk HPV.Detect High Risk HPV. Sample from cervix-Sample from cervix- similar to PAP.similar to PAP. Special transportSpecial transport mediummedium Processed in the labProcessed in the lab HPVHPV Objective testsObjective tests Not suitable for Egypt)Not suitable for Egypt))) ExpensiveExpensive
- 28. VILI:VILI: test-positivetest-positive – Well-defined area.Well-defined area. – Canary yellow .Canary yellow . – Transformation zoneTransformation zone VILI negativeVILI negative – Mahogany brownMahogany brown
- 29. VILI & VIAVILI & VIA Sensitivity Specificity VIA 76.8 85.5 VILI 91.7 85.4
- 30. Limitations of VILILimitations of VILI Stains underwear .Stains underwear . Lugol’s iodine is more expensive than acetic acid.Lugol’s iodine is more expensive than acetic acid. Moderate specificity may result in over-referralModerate specificity may result in over-referral and over-treatment in a single-visit approachand over-treatment in a single-visit approach
- 31. What Infrastructure For VIA?What Infrastructure For VIA? Examination table. Sterile speculum ( Cusco's) Sterile gloves Source of light, a lamp or a torch Cotton swabs Forceps Syringe for acetic acid lavage Acetic acid in dilutions of 3% Recording data
- 32. Via Is An Ideal Alternative to Pap smearVia Is An Ideal Alternative to Pap smear Keep a bottleKeep a bottle of vinegar inof vinegar in your office.your office.
- 33. inexpensiveinexpensive&& 1.1. Simple & quickSimple & quick 2. Immediate results2. Immediate results 3. Not need cytopathologist .3. Not need cytopathologist . 4.4. One step diagnosis and tttOne step diagnosis and ttt.. 55..SensitiveSensitive 66..SpecificSpecific???????????? Advantages of VIA overAdvantages of VIA over PAPPAP
- 34. Disadvantages Of VIADisadvantages Of VIA Lower specificity than the smear test. (May beLower specificity than the smear test. (May be an advantage for women, through over refferal).an advantage for women, through over refferal). Not suitable for endocervicalNot suitable for endocervical glandular disease.glandular disease.
- 35. `` ColposcopyColposcopy How to do VIAHow to do VIA??
- 36. Reporting VisualReporting Visual Inspection FindingsInspection Findings Acetic Acid Test- Negative Aceto-white area(s) not present Acetic Acid Test- Positive Aceto-white area(s) present 1)Density of whiteness 2)Time needed for whiteness to appear and disappear 3)Sharpness of demarcation
- 39. Significance Of Positive VIASignificance Of Positive VIA MinorityMinority :: – may bemay be suspicious ofsuspicious of cancer or CINcancer or CIN.. Majority :Majority : – occur in conditions other than cancer :occur in conditions other than cancer : – Healing orHealing or regenerating epithelium.regenerating epithelium. – Inflammation.Inflammation. – Immature squamous Metaplasia.Immature squamous Metaplasia. – HPV infection.HPV infection.
- 40. Positive VIA Suspicious OfPositive VIA Suspicious Of CancerCancer Rapid uptake of acetic acid (Rapid uptake of acetic acid (less than 20less than 20 seconds).seconds). Slow release of acetic acid(Slow release of acetic acid( more than 2more than 2 minutes)minutes) Sharp raised edges.Sharp raised edges. Irregular surface.Irregular surface.
- 41. Categorize YourselfCategorize Yourself:: Has no ColposcopyHas no Colposcopy VIAVIA ± biopsy± biopsy Has ColposcopyHas Colposcopy One step :( see and treat ).One step :( see and treat ). Two stepsTwo steps What To Do if VIA is Positive &What To Do if VIA is Positive & suspicioussuspicious??
- 42. VIA DISCOVERSVIA DISCOVERS THE CRIMETHE CRIME LOCATES THELOCATES THE CULPRIT +/-CULPRIT +/- COLPOSCOPYCOLPOSCOPY And canAnd can CytologyCytology discoversdiscovers the crimethe crime And needAnd need ColposcopyColposcopy for locatingfor locating the culprit.the culprit.
- 43. Age to initiate screening Age to discontinue screening Screening interval for cervical cytology Post hysterectomy for benign disease ACS (2002( 3years after onset of sexual intercourse, or by age 21 Women may choose, if 70 years and 3 negative tests and no positive tests within last 10 years Annual for conventional cytology: every 2 years for liquid-based cytology; for age >30, every 2 to 3 years after 3 normal consecutive smears and no increased risk Not Indicated ACOG (2003( 3years after onset of sexual intercourse, or by age 21 Inconclusive evidence Annual for age <30; for age >30, every 2 to 3 years after 3 normal consecutive smears, no history CIN 2 or 3, and no increased risk Women may decline testing USPSTF (2003( 3years after onset of sexual intercourse, or by age 21 Age 65, if not at high risk At least every 3 years Not indicated
- 44. Mansoura ExperienceMansoura Experience Int J Gynaecol Obstet.Int J Gynaecol Obstet. 20062006 May;93(2):118-22. Epub 2006 Mar 20.May;93(2):118-22. Epub 2006 Mar 20. Screening for cervical carcinoma using visualScreening for cervical carcinoma using visual inspection with acetic acid.inspection with acetic acid. Abdel-Hady ESAbdel-Hady ES11 ,, Emam MEmam M,, Al-Gohary AAl-Gohary A,, Hassan MHassan M, Farag MK, Abo-Elkheir M, Farag MK, Abo-Elkheir M
- 45. Mansoura ExperienceMansoura Experience J Exp Ther Oncol.J Exp Ther Oncol. 2014;10(4):247-53.2014;10(4):247-53. Human papillomavirus (HPV) is not theHuman papillomavirus (HPV) is not the main cause of preinvasive and invasivemain cause of preinvasive and invasive cervical cancer among patients in Deltacervical cancer among patients in Delta Region, Egypt.Region, Egypt. Thabet M, HemidaThabet M, Hemida R, Hasan M, ElshamyR, Hasan M, Elshamy M, Elfaraash M, Emam M.M, Elfaraash M, Emam M.
- 46. ConclusionsConclusions The easiest female cancer to preventThe easiest female cancer to prevent through screening is cancer cervix.through screening is cancer cervix. Regular ( VIA ) are the best way toRegular ( VIA ) are the best way to prevent cervical cancer in developingprevent cervical cancer in developing counteriescounteries An abnormal Pap testAn abnormal Pap test or ( VIA ) does not mean cancer.or ( VIA ) does not mean cancer.
- 47. Telfax 002/050/2319922Telfax 002/050/2319922 Mobile: 002/01223475579Mobile: 002/01223475579 Email. mae335@hotmail.comEmail. mae335@hotmail.com
Editor's Notes
- #28: The third test that is being assessed by ACCP is HPV test. Currently available tests need lab processing. However efforts are under way to develop HPV tests which can provide immediate results. PATH’s new project is working on this. Fortunate…
- #29: Slide overview: The well-defined, mustard-yellow lesions in the transformation zone indicate cervical intraepithelial neoplasia. Note for bullet 1: The squamocolumnar junction (SCJ) is the point at which columnar cells meet ectocervical squamous cells on the cervix. This junction marks the furthest extent of the transformation zone towards or, in the case of post-menopausal women, into the cervical canal.
- #30: Slide overview: The test performance of each screening method is rated by its sensitivity and specificity. Before discussing VILI’s test performance, it is important to understand what sensitivity and specificity mean.
- #34: This quote comes from an editorial which accompanied the March 1999 Lancet article on a VIA study in Zimbabwe, on which I was one of the leading investigators. Key words from this quote are “proven” and “simple”
- #38: The picture on your left is the magnified image of a normal cervix after the application of Acetic acid. The picture to your right is the magnified image of a cervix with an abnormal Aceto white lesion- ie a Positive tests.
- #39: Slide 15. Cervical Cancer: Abnormal VIA Atypical acetowhite lesion extending up into the canal —colposcopy and biopsy indicated. Bleeding fungating lesion—probable cancer—colposcopy and biopsy indicated.